The ABC s of School Immunization Requirements { NJ Department of Health Jenish Sudhakaran, MPH Jennifer Smith, MPH, CHES Objectives By the end of this program, attendees will be able to: Recognize the characteristics of various VDP s. Understand the impact of VPD s in NJ and nationally. Identify immunization requirements for school entry/attendance Locate tools for interpreting and applying school I immunization requirements Understand the communicable disease reporting requirements along with the general guidelines for the control of outbreaks in child care and school settings N.J.A.C. 8:57-4 Purpose of N.J.A.C. 8:57-4 New Jersey Administrative Code Title 8: Health Chapter 57: Communicable Disease Subchapter 4: Immunization of Pupils in School To establish minimum immunization requirements for attendance in New Jersey schools 1
Religious Exemption Parent or guardian must provide a signed written statement Must contain the word religion or religious or some reference thereto Those persons charged with implementing administrative rules at N.J.A.C. 8:57 4.4 should not question whether the parent s professed religious statement or stated belief is reasonable, acceptable, sincere and bona fide Religious-affiliated schools cannot be challenged on decision The religious exemption does not need to state the child s religion or specific tenants, notarized, or signed by a religious leader No annual update is required Religious Exemption (2) Parents may object to one or more vaccines Parents can file for a religious exemption even if a child was previously vaccinated, because their beliefs have changed Religious exemptions are null & void if vaccines are received after filing date. However, parents can file for a new exemption. Medical Exemption Can only be written by a medical doctor, doctor of osteopathic medicine and an advanced practice nurse licensed to practice in the United States Must indicate a specific time period Reason(s) for medical contraindication must be enumerated by the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) Do not necessarily need to be renewed annually, but should be reviewed periodically Precautions are not contraindications Precaution and Contraindication Precaution Increase the chance or severity of an adverse reaction, or Compromise the ability of the vaccine to produce immunity Contraindication A condition in a recipient that increases the chance of a serious adverse reaction Guide to Vaccine Contraindications and Precautions: http://www.immunize.org/catg.d/p3072a.pdf 2
Exempted Students Those children who have been granted medical and/or religious exemptions may be excluded from the school, preschool, or childcare facility during a vaccine preventable disease outbreak (as determined by the State and Local Health Department). N.J.AC. 8:57-4.3 (d) and 8:57-4.4 (d) Students must: Provisional Admission Have at least one dose of each required vaccine Be actively in process of completing series as rapidly as medically feasible Children < five years of age: allowed up to seventeen to complete Children > five years of age and older: allowed up to twelve to complete ** Note: Seventeen and twelve for completion apply only to those who have never been vaccinated and are starting their vaccination series for the first time. All others should follow the minimum interval schedule. Out of Compliance 30-Day Grace Period The student does not have an immunization record, RE or ME on file, or does not meet the provisional definition since the interval to receive the next dose in the vaccination series has been exceeded Students should not be allowed to attend school until they have a minimum of one dose in the vaccine series and is on schedule to receive subsequent doses consistent with the ACIP catch-up schedule Applies only to out-of-state or out-of-country transfer students The student shall be admitted temporarily for up to 30 days if acceptable evidence of vaccination is not available If after the 30 days have elapsed and no documentation of previous vaccination is provided, the child may not attend school until one dose of all age-appropriate required vaccines are received before being provisionally admitted 3
Four-Day Grace Period All doses administered less than or equal to four days before either the specified minimum age or dose spacing interval shall be counted as valid and revaccination would not be required **Note: ACIP states 2 nd dose is invalid if 2 live virus vaccines is less than 28 days and therefore the 2 nd dose needs to be repeated. NJ would accept all vaccines given within 4 days of the dose spacing interval or minimum age for the purpose of school attendance and auditing. Official Immunization Record Presented on the first day of school List the type of immunization and the date of administration Vaccine administration dates should be listed by month, day and year. Documentation of only month and year are acceptable if the minimum intervals can be determined. For example: 1. A child born on January 15, 2013 received his MMR vaccine in January 2014. -- Not acceptable 2. A child born on January 15, 2013 received his MMR vaccine in February 2014. -- Acceptable 4
Official Immunization Record (2) Examples of documents accepted as evidence of immunizations: -- IMM-8: Department of Health; Standard School/Childcare Immunization Record (Yellow Card) -- A-45 : Department of Education; State Health History and Appraisal Form -- New Jersey Immunization Information System (NJIIS) Official Immunization Record Foreign Immunization Record Accept with proper written documentation - seal or stamp OR - signed and dated by health care provider Be skeptical Match up with U.S. requirements (specifically NJ) Revaccinate in accordance with the ACIP Recommended Schedule (may be simpler) or do serology (when possible) Translation of foreign vaccines: http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appen dices/b/foreign-products-tables.pdf See AAP s Red Book or the ACIP for further guidance New Jersey Immunization Information System (NJIIS) Consolidates immunization information from all providers into one record to provide an accurate immunization assessment and eliminate the use of manual vaccine administration logs Assists federal, state and local public health agencies with population assessments in the event of a preventable disease outbreak NJIIS Mandatory Participation N.J.A.C. 8:57-3.16 a : Every healthcare provider administering vaccines to children less than seven years of age shall register as an NJIIS site and authorized user and commence online reporting of vaccinations prior to December 31, 2011, in compliance with this subchapter Helps communities assess their immunization coverage and identify pockets of need 5
NJIIS Benefits for Schools/Preschools and Childcare Facilities Comprehensive reporting feature: - Assess immunization coverage by age groups. - Track and remind students about missing immunizations. - Add past immunization history to achieve a more accurate vaccination record and to easily transfer students records between schools. Future Enhancements include efforts to streamline annual reporting and auditing procedures. Reporting Requirements Annual Immunization Status Report (ASR) ASR packets are mailed in November of the respective academic year Accessible on-line during the reporting period at: http://nj.gov/health/cd/imm7/annualstatusrpt.shtml Reporting time frame is from September through December 31 st Due February 1 st of respective academic year ASR Follow-up All schools (including childcare and preschool facilities) who have not submitted the ASR by February 1 st will be considered delinquent Delinquent notices are mailed to the schools informing them that they must submit the report by the extension. A delinquent school list is shared with each respective Local Health Department so they can follow up with schools in their jurisdiction Schools who do not submit the report by the extension date may be reported to the respective State agency (i.e. Department of Children and Families/Office of Licensing or Department of Education) and may be subject to the violations statute Violation to the State Sanitary Code Each violation of any provision of the State Sanitary Code shall constitute a separate offense and shall be punishable by a penalty of not less than $50 nor more than $1000 N.J.S.A. 26:1A-10 6
Applicability All students Vaccine Requirements All schools (public and private) including: - Day care, - Nursery school, - Preschool, - Kindergarten Authority Principal/School Administrator Local Health Department Diphtheria, Tetanus, Pertussis Disease Information and NJ School Immunization Requirements Diphtheria causes a thick covering in the back of the throat Breathing problems, paralysis, heart failure, and even death Children > 5 years: as many as 1 out of 5 children who get diphtheria dies Tetanus (Lockjaw) causes painful tightening of the muscles, usually all over the body "locking" of the jaw difficulty opening mouth/swallowing Death in up to 2 out of 10 cases Pertussis (Whooping Cough) causes coughing spells so bad that it is hard for infants to eat, drink, or breathe. These spells can last for weeks. Pneumonia, seizures (jerking and staring spells), brain damage, and death About half of babies < 1 year need care in the hospital. About 1 out of 4 hospitalized babies with whooping cough will get pneumonia 7
DTaP Vaccine Child Care/Preschool: A minimum of four doses of a DTaP-containing vaccine or fewer as appropriate for the child s age per the ACIP Recommended Schedule At this age the student should have received the following vaccine: 2 4 6 12 15 18 19 20-59 Diphtheria, tetanus & acellular pertussis (DTaP) Dose #1 Dose #2 Dose #3 Dose #4 Kindergarten/First Grade: A total of 4 doses with one of these doses on or after the 4th birthday OR any 5 doses DTaP Vaccine Second Grade and Higher (at least seven years of age): A minimum of three doses of a DTaP-containing vaccine Doses of diphtheria, tetanus (DT) are only acceptable if a child has a valid medical contraindication (reason for not receiving) the pertussis component Tdap Vaccine Sixth Grade and Higher: Those children born on or after January 1, 1997 AND who are at least 11 years of age and older are required to receive a one-time dose of tetanus, diphtheria, acellular pertussis (Tdap) vaccine at the six grade or higher grade level 8
Polio Polio virus May cause fever, sore throat, nausea, and headache Most people won t have symptoms In rare cases, can cause paralysis (can't move arm or leg), and it can cause meningitis (infection of the membranes that cover the brain and spinal cord). Risk of lifelong paralysis Polio Vaccine Child Care/Preschool: A minimum of 3 doses of a polio-containing vaccine or fewer as appropriate for the child s age as per the ACIP Recommended Schedule At this age the student should have received the following vaccine: Inactivated Polio Virus (IPV) 2 4 6 Kindergarten/First Grade A total of 3 doses with one of these doses given on or after the 4th birthday OR any 4 doses 12 15 18 Dose #1 Dose #2 Dose #3 19 20-59 Polio Vaccine Second grade and Higher (at least seven years of age): Children who are seven years of age and older are required to have a minimum of three doses of polio Polio vaccine is not required for students 18 years of age and older. Measles, Mumps, Rubella Measles virus causes rash, cough, runny nose, eye irritation, and fever Ear infection: 1 out of 10 children Pneumonia: 1 out of 20 For every 1,000 children who get measles, one or two will die Mumps virus causes fever, headache, muscle pain, loss of appetite, and swollen glands Most children infected with mumps recover fully Can cause meningitis, deafness, and in rare cases, death Rubella virus causes rash, arthritis (mostly in women), and mild fever 85 out of 100 babies born to mothers who had rubella in the first 3 of her pregnancy will have a birth defect 9
Measles, Mumps, Rubella Vaccine Child Care/Preschool: A minimum of one dose of MMR vaccine by 15 of age Travel Recommendation: 6 through 11 of age who will be traveling internationally. This dose would not count towards completion of the routine schedule. Kindergarten-Twelfth Grade: Two doses of measles, one dose of mumps, and one dose of rubella Haemophilus influenzae type b (Hib) Haemophilus influenzae, causes different symptoms depending on which part of the body is affected. The most common severe types of Haemophilus influenzae disease are: o Pneumonia o Bacteremia (bloodstream infection) o Meningitis Before Hib vaccine, Hib disease was the leading cause of bacterial meningitis among children under 5 years old in the United States Haemophilis influenzae type b (Hib) Vaccine Child Care/Preschool: Children who are 2 through 11 of age: Minimum of two age-appropriate doses Children who are 12 through 59 of age: Minimum of one dose on or after the first birthday At this age the student should have received the following vaccine: Haemophilus influenzae type b (Hib) 2 4 Kindergarten-Twelfth Grade: Not Required 6 12 Dose #1 Dose #2 1-4 doses 15 18 At least one dose given on or after the first birthday 19 20-59 Hepatitis B Hepatitis B virus can cause liver damage, liver cancer, and death Loss of appetite, tiredness, pain in muscles, joints, and stomach, jaundice (yellow skin or eyes) Infants, young children, and people with lifelong hepatitis B usually show no symptoms. Babies can get hepatitis B at birth from their infected mother Infants and young children: 90% chance of developing a life-long, chronic infection 10
Child Care/Preschool: Not required Hepatitis B Vaccine Kindergarten-Twelfth Grade: Three doses of hepatitis B vaccine or any vaccine combination containing hepatitis B virus OR An approved 2-dose adolescent vaccine for 11-15 year olds Varicella (Chickenpox) Varicella virus causes a rash, itching, fever, and tiredness. Most children completely recover in a week, but the itching can be very uncomfortable Can cause serious problems including: o Bacterial infection of the skin and tissues under the skin (including Group A streptococcal infections) o Dehydration (loss of body fluids) from vomiting or diarrhea o Pneumonia o Encephalitis (brain swelling) Varicella (Chickenpox) Vaccine Child Care/Preschool: A minimum of one dose of varicella vaccine by 19 of age (for children born on or after January 1, 1998) Kindergarten-Twelfth Grade: At least one dose of varicella vaccine. Pneumococcal Disease Children under 2 years of age are among those most at risk for disease Pneumococcal disease causes different symptoms depending on which part of the body is affected: o Pneumonia o Bacteremia (bloodstream infection) o Meningitis (infection of the covering of the brain and spinal cord) o Otitis Media (middle ear infections) About 4,000 cases of serious disease (meningitis and sepsis) occur each year in children under 5 in the U.S. These illnesses can lead to disability like deafness, brain damage, or loss of arms or legs 11
Child Care/Preschool: Pneumococcal Vaccine Children who are 2 through 11 of age: Minimum of two age-appropriate doses Children who are 12-59 of age: Minimum of one dose on or after the first birthday At this age the student should have received the following vaccine: Pneumococcal conjugate (PCV 13) 2 4 6 12 15 Dose #1 Dose #2 1-4 doses At least one dose given on or after the first birthday 18 19 20-59 Influenza (Flu) Influenza (Flu) virus causes chills, sore throat, headache, muscle aches, tiredness Causes more hospitalizations among young children than any other vaccine-preventable disease Each year, approximately 20,000 children under the age of 5 are hospitalized because of flurelated complications Kindergarten-Twelfth Grade: Not Required Influenza Vaccine Meningococcal Disease Child Care/Preschool: Children who are 6 through 59 of age are required to receive at least one dose of influenza vaccine before December 31 of each year Kindergarten-Twelfth Grade: Not required Can cause two types of infection: Meningococcal meningitis infection of covering of brain and spinal cord o brain damage, hearing loss, learning problems Meningococcemia (septicemia) a serious blood infection o loss of arms, legs, or other body parts Can become deadly in 48 hours or less 12
Meningococcal Vaccine Child Care/Preschool: Not required Sixth Grade and Higher: Those children who were born on or after January 1, 1997 AND who are at least 11 years of age and older are required to receive a one-time dose of meningococcalcontaining vaccine at the six grade or higher grade level. Meningococcal Conjugate Vaccine is preferred. Meningococcal Vaccine Recommendations by Age and/or Risk Factor: http://www.immunize.org/catg.d/p2018.pdf Laboratory Evidence of Immunity Accepted for measles, mumps, rubella, hepatitis B, diphtheria, tetanus, polio and varicella Serology should not be done in lieu of aborting series No reliable serologic test exists for pertussis, Haemophilus influenzae type b, pneumococccus and meningococcus Copy of laboratory test must be in the record 13
Resource Links State VPDP : http://www.nj.gov/health/cd/vpdp N.J.A.C. 8:57-4: http://lexisnexis.com/njoal Instructions for viewing regulations: http://nj.gov/health/cd/documents/instructions_viewing_regulations.pdf NJ Vaccine Requirements and Guidance Materials: http://nj.gov/health/cd/imm.shtml Antibody Titer Law: http://nj.gov/health/cd/documents/antibody_titer_law.pdf NJIIS website: https://njiis.nj.gov/njiis/ 2014 ACIP Recommended Childhood & Adolescent Immunization Schedule: http://www.cdc.gov/vaccines/schedules/index.html 2014 Catch-up Schedule: http://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html Resource Links ACIP recommendations: http://www.cdc.gov/vaccines/hcp/acip-recs/index.html ACIP Guide to Contraindications and Precautions to Commonly Used Vaccines: http://www.immunize.org/catg.d/p3072a.pdf Centers for Disease Control and Prevention (CDC) Provider Resources for Vaccine Conversations with Parents: www.cdc.gov/vaccines/conversations Immunization Action Coalition (IAC): http://www.immunize.org/catg.d/p2070.pdf Southern Regional Governmental Public Health Partnership/New Jersey: http://www.sjhealthapp.org/ Immunization Apps for Health Care Providers and Patients: http://www.immunize.org/resources/apps.asp 14
In 1736 I lost one of my sons, a fine boy of four years old, by the small-pox, taken in the common way, he wrote. I long regretted bitterly, and still regret that I had not given it to him by inoculation. This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it, my example showing that the regret may be the same either way and that, therefore, the safer should be chosen. The ABC s of School Outbreak Reporting NJ Department of Health Elizabeth F. Zaremski, MPH Purpose of Reporting Control further spread of the disease Identify and eliminate sources Learn about emerging problems Identify carriers Minimize disease transmission Implement new strategies Prevention within schools Outbreak and Case Reporting Mandated by New Jersey Administrative Codes and Statutes. N.J.A.C. 8:57 (Health) Communicable Diseases N.J.A.C. 6A:16-2 (Education) General Provisions for School Health Services N.J.A.C. 10:122 (Human Services) Manual of Requirements for Child Care Centers http://www.nj.gov/health/cd/reporting.shtml 15
Who Should Report? Health care providers Administrators Persons having control or supervision over a child care center, school, youth camp Laboratories When to Report? As soon as an outbreak is suspected A significant increase of illness above what is expected in a given period of time Current infection control practices are not working to control the spread of illness among the students/staff What is an Outbreak? Occurrence of disease above the expected norm during a defined time period Several cases within a classroom/wing of a facility or attended a common event/activity Increase in absences with similar reported reason Two or more students diagnosed with same reportable disease Single case of highly infectious disease Report Outbreak to Who? Report to the local health department (LHD) where the school is located http://localhealth.nj.gov If the LHD cannot be reached, call the NJ Department of Health (NJDOH) (609) 826-5964 normal business hours (609) 392-2020 after hours/holidays 16
http://www.cdc.gov/pertussis/surv-reporting.html *Please note 2013 & 2014 data are provisional http://www.cdc.gov/measles/ *Please note 2013 & 2014 data are provisional 17
Outbreak Management Identify an Outbreak Compare numbers of current cases to expected norms Provide total number of students and staff Maintain a daily log of absent students and staff Ask parent to provide reason for absenteeism Identify an Outbreak Verify the diagnosis Determine the cause Laboratory evidence Clinical signs and symptoms Physician diagnosed illness Control the Outbreak Local health department to provide guidance School to institute and maintain recommended control measures Common control measures may be found at http://nj.gov/health/cd/outbreaks.shtml 18
Exclusions Ill children should be excluded until they are no longer considered infectious Specific exclusion criteria can be found at http://nj.gov/health/cd/outbreaks.shtml Exclusions Determine if there are any un-/undervaccinated persons exposed Medical or Religious Exemption Age Decision to exclude should be made in consultation with LHD and NJDOH Every situation may be different Disease Outbreak vs single case Exposure Other Steps Develop an outbreak case definition Perform active surveillance Document and count cases Identify and eliminate the source Evaluate the effectiveness of control measures and modify, as needed Closures NJDOH does not recommend school closure for outbreaks of infectious disease Administrative decision After consultation with public health officials and school district medical personnel 19
Closures If necessary, utilize closure on limited basis to prevent spread of infection When Infections expected to affect large number of susceptible individuals Control measures are inadequate Facility unable to function due to increased illness affecting staff Education Health education for students, staff, and parents is an essential component in the prevention and control of communicable diseases Should be done before problems arise Parental Notifications Policy for notification to parents Post signage and/or send notification home Sample notification letter template can be found at: http://nj.gov/health/cd/outbreaks.shtml http://www.nj.gov/health/cd/vpdp/index.shtml Communication to parents should include assistance from local public health What to Convey Communicate in ways that build, maintain or restore trust Provide simple, straightforward, and realistic messages Deliver information with brevity, clarity, and effectiveness Include symptoms, prevention and control measures, exclusion Provide actions school has taken and what parents can do 20
Summary Familiarize yourself with NJDOH guidance available at http://nj.gov/health/cd/outbreaks.shtml Communicate Get to know your local health department Be prepared Develop policies Review vaccination records Report Resources NJDOH Communicable Disease Service http://www.nj.gov/health/cd Centers for Disease Control and Prevention http://www.cdc.gov http://www.cdc.gov/vaccines CDC Pink Book http://www.cdc.gov/vaccines/pubs/pinkbook/index.html CDC Manual for Surveillance of VPDs http://www.cdc.gov/vaccines/pubs/surv-manual/index.html AAP Red Book http://aapredbook.aappublications.org Contact Vaccine Preventable Disease Program Phone: (609) 826-4861 Fax: (609) 826-4866 Communicable Disease Service Phone: (609) 826-5964 21